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Burnett Co ty Office of Zoning Administrator o H z <br /> PLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 * • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a '" -- ..‘N*. <br /> Permit for the work described and located as shown herein. The undersigned agrees that all \ <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, m \ <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu CD °- <br /> lations of the State of Wisconsin. - a <br /> r+ m <br /> D‘\' k• <br /> Owner or Agent (please print) Contractor or Surveyor N ` <br /> T i . . w ',e,sii c S'Y1'7.. Q <br /> Address Address a <br /> CD <br /> 0 <br /> Phone Phone 'tel <br /> C4Drcrr4 SC/i IR5Wee -1/4,N,'. ....,.\\s % <br /> Plumber Well Driller <br /> Address Address v `c-D) GO <br /> AVs ``T o <br /> S~_ sii0 o <br /> Phone Phone H r- <br /> 0 <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ,. v <br /> Type o tri tion No. Bathrooms o Z <br /> 1. Work No. Bedrooms 3 ° CD <br /> New Building Si e x ft. Septic Tank Size Gals. /000. \ (� <br /> Addition ' / Height Stories �\; V. <br /> Sanitary (�. Area 7a.Absorption Field Site: "' i <br /> 1— <br /> FillingSoil Type . . . .+./.�/VP �I <br /> Moving 5. Permits Required Slope A le 41n 1 7 <br /> Grading Subdivision Perc. Rate X <br /> Mobile Home Sanitary Dry Well nCD <br /> CD I <br /> Privy Building Seepage Trench I <br /> 1151 - <br /> Well Well Privy <br /> Subdivision Other (Specify) Seepage Bed . Xi <br /> Conditional • cn cn <br /> 2. Classification Land Use cr <br /> Zoning Dist. . . I. °• o <br /> 6. Use (describe exactly, 1 - fam. 0 \ �• ) <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE `Q ° <br /> • it0. . . . ft. x e7‘20. . . ft. �� F�l// Plans Submitted ` N <br /> sq. ft. 4101, Y '[�rrre" Plans Approved C <br /> Fig. g___-- <br /> A. Location of proposed structures and <br /> existing structures, well, sewage sys- > o <br /> tems, roads, etc., should be sketched D <br /> in Fig. A. Include road setback, side "1 <br /> and back yard dimension and location ' 1 o <br /> and setback from all bodies of water. <br /> (0( <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways <br /> As <br /> / and the setbacks required along <br /> them and at the intersection. a <br /> NDo <br /> PERMIT FEES <br /> D <br /> 1 to <br /> Subdivision $25.00 + $2.00 per lot. ' `D <br /> Land Use $10.00 ' <br /> •'• = 10.00 6' <br /> k <br /> f..0.7... . <br /> We 10.0 0 `4— <br /> Septic Tank 10.00 <br /> Privy 5.00 <br /> eipzi bz9 4,4L.„ ,7//69 <br /> 1 i a 1 Jad/////4"-\------ <br /> Signature of Owner or Agent ge D <br /> a Zoning Administrator !�` <br /> Inspection Date `.L ...) GY 4 Inspector ..�„e- ,7...t stY„'.1`,-i.:q.(e2',- .c; / <br /> Remarks ', e < --z)---.”. _;c,....1-' a. �1i,-4.z.�Z :.Rt. '..2/;-4'z/. <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />